HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2
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Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521
Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting three of nine levels.
Findings include:
Document review on April 1, 2024, at 9:00 a.m., revealed the May 15, 2023, fire damper inspection report listed the following deficiency: (8) Fire Dampers did not function properly on 5/15/23 and need to be replaced. Documentation of subsequent repairs was not available at time of survey.
Exit Interview with the Administrator and Maintenance Director on April 1, 2024, at 11:35 a.m., confirmed the missing documentation.
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Based on document review and interview during an onsite revisit conducted on June 5, 2024, the following was determined:
Not Completed. The fire damper inspection report listed the following deficiency: (8) Fire Dampers did not function properly on 5/15/23 and need to be replaced. Documentation of subsequent repairs was not available at time of survey.
Exit Interview with the Maintenance Director on June 5, 2024, at 10:30 a.m., confirmed the missing documentation.
| | Plan of Correction - To be completed: 06/30/2024
Industrial Mechanical Contractors, Inc. was retained on 4/15/2024 by Welsey Enhanced Living Doylestown to replace the deficient fire dampers on floors 3,4,5 and 6. The hard ceilings have been removed, demolition has commenced, and material has been ordered.
Due to the custom sizing of the dampers these were a long lead time. Industrial Mechanical anticipates the fire dampers to be in hand with installation commencing 5/30. The work is in progress and is anticipated to be completed on or about June 17, 2024.
Once the work is completed, the Director of Facility Operations will send the paperwork to the Field Office.
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